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British Journal of Urology (1998), 82, 196–198

REVIEW
Urinary bladder wall repair: what suture to use?
K.M .I. PAL
Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan

strength is decreased and they are absorbed in tissues


Introduction
through degradation by acid hydrolytic and collageno-
At present there are no clear guidelines as to the most lytic enzymes. To improve their tensile strength and
suitable suture material available for the closure of resistance to enzymatic digestion, the material is treated
urinary bladder wall defects; the general tendency is to with aldehyde solution and chromium trioxide, produc-
use one of the synthetic absorbable suture materials. ing ‘chromic’ catgut. Despite rigorous quality control,
The interior of the urinary bladder is encountered often these sutures tend to have a variable loss of tensile
by any surgeon opening the abdomen routinely. The strength and absorption time.
fluid nature of its contents, with a high concentration The synthetic absorbable sutures most commonly used
of solutes, predisposes to both a susceptibility to infection at present are derived from a-polyesters. The polymers
and a propensity to form concretions, especially on used for their construction are inherently rigid and thus
foreign bodies. can be used as monofilaments only in the finest gauge.
It is now accepted practice that only absorbable suture For clinical use, the fine filaments have to be braided to
material should be used to repair bladder wall defects, produce diCerent suture sizes. The first to be introduced
although initial experimental evidence had suggested was polyglycolic acid (PGA, Dexon@), which was fol-
that polypropylene (a monofilament nonabsorbable lowed by polyglactin 910 (Vicryl@). Monofilament
suture) could be used in urological procedures [1–4]. Of absorbable suture such as polydioxanone (PD) has also
the absorbable sutures, the earliest available and most been developed. Synthetic absorbable sutures appear to
frequently used until recently was chromic catgut. With be chemically degraded by the nonenzymatic hydrolysis
the introduction of a variety of synthetic absorbable of ester bonds; their loss of tensile strength and physical
sutures, much attention has been given to their use in structure in tissues is more uniform and can be predicted
bladder surgery. more accurately.
At present there is no simple answer to the choice of
which suture is best suited for bladder repair. An ideal
suture should have good handling and knot-holding Sutures used in bladder repair
properties, should induce no tissue reaction and be To define the best suture material for bladder repair, the
absorbable, but maintain its strength long enough for following areas were examined: (i) tissue/material inter-
sound healing to take place. In addition, for the urinary action; (ii) gain in tissue strength through healing in
bladder it should not be aCected by urinary constituents relation to the loss of tensile strength in the suture
or by infected urine, and should not be lithogenic. In material with time; (iii) changes in suture tensile strength
practice, the issue of cost must also be addressed in this with time; (iv) changes in suture tensile strength on
definition, for cost is increasingly important in providing contact with uninfected and infected urine; (v) the
quality medical care. Indeed, currently it must be shown lithogenic potential of diCerent materials. Unfortunately
that there is an objective clinical advantage of one most of the answers available relate to either laboratory
treatment methodology over another, rather than a conditions or animal models; whether results from these
perceived theoretical superiority. sources can be extrapolated to clinical settings in their
entirety is open to question.
Types of absorbable sutures The inflammatory response to suture materials has
been of concern in all types of tissues. It is thought that
Absorbable sutures are made from either collagen the more intense the inflammatory response, the slower
(catgut) or synthetic polymers. In the former, the tensile the gain in wound strength because of the greater local
degradation of collagen. Catgut sutures have been shown
Accepted for publication 12 February 1998 to cause the greatest inflammatory response in several

196 © 1998 British Journal of Urology


UR INARY B LADDE R WALL REPAI R 197

tissues [5]. Studies have compared tissue inflammatory retained significant strength; bladder wall wound
response in the urinary bladder, for diCerent suture strength is then >80% of the normal unwounded
types, in animal models. In rabbits, on microscopic wall [8].
examination there was no diCerence in the inflammatory The ability of various suture materials to maintain
reaction between 5/0 catgut, 5/0 PD and polypropylene their strength while exposed to sterile and infected urine
[6]. In rats, PD had the greatest inflammatory response has been examined [15]. In sterile urine, PD lost its
initially, although catgut, PD and polyglactin had a strength and became fragmented after 3–6 days; PGA
similar response at 6 months [7]. The clinical significance gradually lost strength, losing 74% of its original strength
of moderate diCerences in inflammatory response at the by 10 days. Catgut showed little change in its breaking
microscopic level is debatable. strength over the 10-day period. In acidic urine infected
The urinary bladder is one of the weakest organs with Escherichia coli PD lost all its strength after 6–10
where unwounded wall strength is concerned, compar- days; PGA lost 72% of its original strength after 10 days.
able with the colon [8]. On healing, it behaves diCerently Conversely, catgut had lost only 8% of its original
to other tissues, having a very rapid gain in wound breaking value. In alkaline urine infected with Proteus
strength after approximation of the edges. The force spp, PD sutures disintegrated over 3 days; PGA sutures
needed for tissue disruption approaches that of reacted similarly, with sutures completely dissolving by
unwounded tissue 14–21 days after wounding in animal the second day. However, catgut showed a rise in
models [8]. breaking strength during the first 24 h and had only
An argument proposed for the use of synthetic lost 6% of its original strength after 10 days.
absorbable sutures is the extended tissue support pro- Studies on the lithogenic properties of various suture
vided, for up to 3–4 weeks. Tissues with comparable materials have shown that lithogenesis is proportional
tensile strength, e.g. colon and stomach, attain 50–70% to the duration of absorption of the material. The highest
of normal tissue strength 120 days after the surgical incidence has been noted with nonabsorbable braided
closure of wall defects [8,9]. Unwounded tissues appar- suture material; monofilament nonabsorbable sutures
ently have an inherent strength many times more than have similar problems, confirmed in experimental and
that needed for the normal physical stress of their clinical settings [2,3,8]. The use of both these types has
particular function, thus the argument about longer been discontinued for bladder repair.
support loses its force. Barham et al. [10] have shown One of the major disadvantages of animal-based stud-
that only in irradiated bladder tissue is the healing ies has been the species-specific diCerences in lithogenic
wound strength statistically better with the use of syn- potential for diCerent sutures [2]. In the rabbit, with
thetic absorbable sutures. alkaline urine and very high susceptibility to stone
The loss of suture tensile strength with time is an formation in experimental settings, the lowest incidence
important and often reported issue; absorbable sutures of concretion was with chromic catgut, the highest with
lose tensile strength predictably in tissues with time, polypropylene and intermediate with PD [6]. In another
more so than the synthetic variety. The tissue disruption study conducted in the rat [7] the lithogenic potential
force for normal bladder is #400 g/cm [8]. The suture of all three materials was similar, although the urine
breaking-strengths of 2/0 and 3/0 sutures, i.e. those was never alkaline. In dogs, none of the sutures tested
commonly used in bladder repair, are given in Table 1 led to stone formation [2].
[11–13]. These sutures all have breaking strengths
many times the force required for disruption in normal
Conclusion
tissues. Sutures lose # 40% of their original strength on
forming a secure knot, the latter being the weakest part Of the absorbable sutures, chromic catgut has been used
[14]. After 2 weeks, all three types of absorbable suture the longest and has stood the test of time. The synthetic
absorbable sutures have some theoretical advantages
Table 1 Tensile strength (g) of standard dry sutures [11,12] and but there have been no studies on humans to date where
15 days after implantation in the subcutaneous tissues of rabbit [13] these advantages have been shown to be clinically
significant. Laboratory experiments and studies on ani-
Size (dry) Size (implanted)
mals have given conflicting results and can be interpreted
Suture type 3/0 2/0 3/0 2/0 either way, depending on personal bias. As to rec-
ommending which suture to use in repair of the urinary
Chromic catgut 3000 4454 272 545 bladder, it can be safely stated that currently there is no
Polyglycolic acid 2772 4363 977 909 suture material that has been convincingly shown to be
Polyglactin 910 NA 5331 NA 3245 better than chromic catgut in clinical trials. If no clinical
advantage can be shown, then cost is increasingly

© 1998 British Journal of Urology 82, 196–198


198 K. M.I . PAL

significant. There is a considerable diCerence in the price 8 Hastings JC, Van Winkle W Jr, Barker E, Hines D,
of diCerent absorbable sutures: chromic catgut, polyglac- Nichols W. The eCect of suture materials on healing
tin 910 and PD cost (per 12, in rupees) 225, 1200 and wounds of the bladder. Surg Gyn Obs 1975; 140: 933–7
2500, respectively, i.e. the polyglactin and PD cost 4.9 9 Hastings JC, Winkle WV, Barker E, Hines D, Nichols W.
ECect of suture materials on healing wounds of stomach
and 10 times the catgut (prices from Ethicon Ltd,
and colon. Surg Gyn Obs 1975; 140: 701–7
Pakistan). Thus, after reviewing the available evidence
10 Barham RE, Butz GW, Ansell JS. Comparison of wound
it reasonably certain that there is no convincing evidence strength in normal, radiated and infected tissues closed
for discontinuing the use of chromic gut in the repair of with polyglycolic acid and chromic catgut sutures. Surg
the urinary bladder. Gyn Obs 1978; 146: 901–7
11 Katz AR, Turner RJ. Evaluation of tensile and absorption
properties of polyglycolic acid sutures. Surg Gyn Obs 1970;
References 131: 701–16
1 Bartone FF, Stinson W. Reaction of the urinary tract to 12 Howes EL. Strength studies of polyglycolic acid versus
polypropylene sutures. Invest Urol 1976; 14: 44–6 catgut sutures of the same size. Surg Gyn Obs 1973;
2 Kaminske JM, Katz AR, Woodward SC. Urinary bladder 137: 15–20
calculus formation on sutures in rabbits cats and dogs. 13 Craig PH, Williams JA, Davis KW et al. Biologic comparison
Surg Gyn Obs 1978; 146: 353–7 of polyglactin 910 and polyglycolic acid synthetic
3 Healey GB, Warren MM. Stone formation on polypropylene absorbable sutures. Surg Gyn Obs 1975; 141: 1–10
suture. J Urol 1979; 121: 836–7 14 Rodeheaver GT, Thacker JG, Owen J, Strauss M,
4 Yudofsky SC, Scott FB. Urolithiasis on suture materials: its Masterson T, Edlich RF. Knotting and handling character-
importance, pathogenesis and prophylaxis: an introduction istics of coated synthetic absorbable sutures. J Surg Res
to the monofilament Teflon suture. J Urol 1969; 102: 1983; 35: 525–30
745–9 15 El-Mahrouky A, McElhaney J, Bartone FF, King L. In vitro
5 Van Winkle W, Hastings JC. Considerations in the choice comparison of the properties of polydioxanone, polyglycolic
of suture materials for various tissues. Surg Gyn Obs 1972; acid and catgut sutures in sterile and infected urine. J Urol
135: 113–26 1987; 138: 913–5
6 Morris MC, Baquero A, Redovan E, Mahoney E, Bannet
AD. Urolithiasis on absorbable and non-absorbable suture
materials in the rabbit bladder. J Urol 1986; 135: 602–3 Author
7 Stewart DW, BuBngton PJ, Wachsman J. Suture material K.M.I. Pal, FRCS, MSc, Department of Surgery, Aga Khan
in bladder surgery: a comparison of polydioxanone, polyg- University Hospital, Stadium Rd, PO Box 3500, Karachi
lactin, and chromic catgut. J Urol 1990; 143: 1261–3 74800, Pakistan.

© 1998 British Journal of Urology 82, 196–198